Etiology

Overview

Details

Mechanism	Comment
Biogenic amines	Histamine intolerance Wine contains histamine (red > white), and alcohol inhibits intestinal diamine oxidase which metabolizes histamine Beer may also contain histamine in varying amounts Biogenic amines other than histamine: most commonly implicated are tyramine and phenylethylamine (both associated with headache)
Sulfites	Wine contains large amount of sulfites (>100 ppm) Sulfite sensitivity may cause bronchoconstriction or wheezing
Alcohol intolerance due to decreased aldehyde dehydrognase2 (ALDH2) activity	Build up of acetaldehyde due to decreased enzyme activity causes degranulation of mast cells, usually causing a nonelevated, intense erythema to appears over the face and trunk within minutes (usually peaking at 30 min), sometimes with associated nausea, light-headedness, headache, nasal congestion, bronchoconstriction Genetic deficiency: single nucleotide polymorphism (ALDH2*504lys) of acetaldehyde dehydrogenase affects 40% of East Asians (nearly absent in whites), known as "Asian flush, blush, or glow" Inhibition by drugs: disulfiram (Antabuse), ketoconazole, griseofulvin, topical tacrolimus, chlorpropamide, cephalosporins cause similar symptoms as genetic deficiency
IgE-mediated reaction to allergens in the alcoholic beverage	Wine proteins Grape (Vitis vinifera) proteins Endochitinase 4A Thaumatin-like protein Vit v 1 (LTP1), which is homologous to peach LTP Grape chitinases, thamautin proteins, and LTP are thought to withstand vinification Fungi involved in fermentation or present on grapes (e.g. noble rot with Botrytis cinerea) Wine contaminated with food proteins used to clarify (fine) wine: egg white (lysozyme, albumin), fish (protein contaminating isinglass fish gelatin), cow's milk (casein), tree-nuts (tannins) Studies demonstrate that this is a very unlikely cause of an allergic reaction to wine even in patients allergic to egg, fish, milk, nuts Hymenoptera venom - insects incidentally pressed with grapes causing a reaction when grape juice/wine ingested by venom-sensitized patients Occurs only with grape juice or fresh wine because venom allergens degrade with time, and sensitivity is specific to that batch of venom-contaminated juice/wine Beer proteins Grains, e.g. barley, wheat Beer allergens may include those in the LTP family (stable during brewing process) Fungi involved in fermentation Hops have been suspected as an allergen in beer reaction but there are no cases showing a causative relationship